Consumer s Guide to Health Insurance Grievances and Complaints

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1 Consumer s Guide to Health Insurance Grievances and Complaints A Consumer s Guide to Resolving Disputes with Your Health Plan State of Wisconsin Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI OCI s Web Site: oci.wi.gov PI-217 (R 09/2015)

2 The mission of the Office of the Commissioner of Insurance... Leading the way in informing and protecting the public and responding to their insurance needs. If you have a specific complaint about your insurance, refer it first to the insurance company or agent involved. If you do not receive satisfactory answers, contact the Office of the Commissioner of Insurance (OCI). To file a complaint online or to print a complaint form: OCI s Web Site oci.wi.gov Phone (608) (In Madison) or (Statewide) Mailing Address Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI Electronic Mail Please indicate your name, phone number, and address. Deaf, hearing, or speech impaired callers may reach OCI through WI TRS This guide is not a legal analysis of your rights under any insurance policy or government program. Your insurance policy, program rules, Wisconsin law, federal law, and court decisions establish your rights. You may want to consult an attorney for legal guidance about your specific rights. The Office of the Commissioner of Insurance does not represent that the information in this publication is complete, accurate or timely in all instances. All information is subject to change on a regular basis, without notice. Publications are updated annually unless otherwise stated. Publications are available on OCI s Web site oci.wi.gov. If you need a printed copy of a publication, use the online order form or call One copy of this publication is available free of charge to the general public. All materials may be printed or copied without permission. 2

3 Introduction Most people will never have a problem with their health insurance. But when you do have a complaint with your plan, it can be difficult to understand the steps you must take to resolve your problem. This booklet serves as a guide to help you understand the grievance and complaint process that all policies sold in Wisconsin are required to offer you. The question and answer format allows you to read straight through, or go right to a particular question you may have. Also included at the end of the booklet is a series of worksheets that will help you to document your complaint process. It is important to remember that not all health plans are subject to the appeal process discussed in this booklet. If your plan is self-funded by your employer, then it is subject to federal, not state law. Public programs like Medicare and Medicaid also have their own processes. Make sure you are aware of what kind of health insurance plan you have before you begin the grievance process described in this booklet. What You Need to Know About Your Health Plan How do I receive medical benefits from my health plan? Most health plans require you to follow certain procedures in order to receive coverage from the plan. If you know the procedures your health plan requires and you follow them, you will less likely have problems when you do get sick. For example, you should know how to file a claim, when you might need prior authorization from your plan, when you need to contact the company, and who your in-network providers are. Familiarize yourself with these procedures before you need health care in order to minimize trouble when you are already dealing with health problems. Is your provider in-plan? If you are in a managed care plan, make sure your provider is in-plan before each visit to ensure you ll receive coverage. Some plans may have more than one benefit level; for example, specialists may require a different copay. Make sure you understand what you will be required to pay. You can verify this by checking the plan s Web site or by calling your insurer. What is covered and what is excluded under my health plan? You should be aware exactly what medical procedures and medications, etc., are covered under your plan in order to avoid planning a procedure that is not covered. You should review your summary of benefits and coverage for a quick overview, but your certificate of coverage will provide a complete picture. 3

4 What if my plan doesn t cover something? No health plan covers everything sometimes not even health care services that are medically necessary or procedures where there is no other option. However, remember that as a consumer you can ask your insurer to cover your procedure if you believe that it is an effective treatment. You can ask that the insurer consider covering the procedure on an exception basis if you believe that it is more effective than a covered procedure. Where do I find answers to these questions? Review your member material, including your policy and your certificate. Your plan s summary of benefits and coverage can provide a quick overview of plan benefits. For coverage of Rx drugs, check your plan s formulary. You can also call your health plan s customer service number or check their Web site for this information. If your plan is employer based, you can talk to your employer s human resources section to find answers. Most importantly, make sure to keep all records. This includes your policy certificate and other member materials, any correspondence from your insurer, letters from providers and/or other documents such as medical records and test results, and also records of all phone calls made to your health plan. The attached worksheets are included to help you document conversations with your insurer. What if coverage is denied? If your plan denies your claim or your request for coverage, you will receive a written notice. This denial notice (or explanation of benefits) should explain why your insurer denied your claim. Your health plan should give you a specific reason for the denial. The notice should also explain your appeal rights. What should I do if I have a complaint? Many complaints or questions can be resolved informally by calling your plan s customer service line. Many health plans also have Web sites that can be helpful in resolving your complaints. If you have questions regarding how to complain to your insurer, call OCI at or visit oci.wi.gov for help filing a complaint. Make sure to keep all records. This includes your policy certificate and other member materials, any correspondence from your insurer, letters from providers and/or other documents such as medical records and test results, and also records of all phone calls made to your health plan. What if I m not satisfied with the results of my complaint? You still have the right to file a grievance. Your denial notice may explain how to do this, or it will tell you how to find these instructions. The denial notice also includes information about your right to have your claim reviewed by an Independent Review Organization. 4

5 What is a grievance? A grievance is any written dissatisfaction with the provision of services, claims practices, or the administration of a health benefit plan. A grievance may be submitted by you or you may authorize someone to submit the grievance on your behalf. For example, a grievance can be filed when your health plan denies your request for a referral, your health plan will not cover a treatment you believe you need, or the quality of your treatment is lacking. In some cases, you may need to resolve your grievance more quickly than the standard grievance process. If this is the case, request an expedited grievance. An expedited grievance means a grievance where any of the following apply: The length of time for a normal grievance resolution would result in serious jeopardy to your life or health or would limit the ability for you to regain maximum function. Your physician requests the expedited process because your pain is too severe to be adequately managed without the care or treatment that you are requesting. Your physician determines that the grievance should be treated as an expedited grievance. How do I file a grievance with my health plan? You may file a grievance by sending a letter to your health plan. Keep the following points in mind when writing and sending your letter: Identify yourself, including your name, address, and health plan ID number. Explain the problem; be specific with dates of service, denial notice, summaries of any phone conversations, and why you believe the plan s decision is wrong. Base your argument on policy language; if you are asking for an exception, explain how coverage could benefit the plan such as avoiding a more expensive treatment that is covered. Clearly state what you want the resolution of your grievance to be. Include photocopies of any supporting documents, such as medical records, referrals, supporting letters from doctors, and articles from peer-reviewed medical journals. If your grievance involves a medical issue, you may want to talk to a doctor and ask if he/she has any records that may support your position. Keep the letter business-like. 5

6 If someone else is sending the grievance for you, include a note signed by you authorizing that person to act on your behalf; most plans will require this. Send the letter to the address provided on the denial notice or in your certificate. What happens next? Your health plan must send you an acknowledgment within five business days of receiving your letter. If you do not receive an acknowledgment, call your plan. Some plans may review the grievance to try to resolve the problem informally. Can I be present at the grievance review? Yes, but you are not required to attend. Your health plan must send you a notice of the time and place of the meeting at least seven days in advance. You have the right to appear in person or by teleconference before the grievance panel where you may present written and oral information and question the decision makers. The grievance panel must include at least one individual authorized to take corrective action, one insured who is not part of the plan, if possible, and may not include the person who made the initial determination. The panel is not required to include a medical professional but should consult one when appropriate. When can I expect to hear from my health plan? Your plan should send you a grievance resolution letter within 30 days of initially receiving the grievance. They may also choose to extend the decision another 30 days but must send you a written notice explaining the reason for the extension. When you do receive a response, it will be in the form of a letter that will either accept or deny your grievance. If your grievance was denied, the letter should explain any additional options, including the right to an independent review. The letter should be signed by one voting member of the panel and include the titles of the panel members. Independent Review Process Both state and federal law give individuals the right to request an independent external review when their health plan denies or reduces coverage of medical services in some circumstances. Although the laws are similar, there are some significant differences. This booklet provides general information on the state process. 6

7 What is an independent review? An independent review is a process that allows an outside expert to provide a second look at your claim. Because the reviewer is not affiliated with you, your medical provider, or the insurer, the reviewer is able to conduct an independent and unbiased review of your claim. The independent review process is intended to be an easy way to allow you to receive an independent decision within a relatively short time frame. You can request an independent review whenever your health plan denies you coverage for treatment based on a medical judgment. For example, you may request an independent review if the health plan maintains that the treatment is not medically necessary according to their definition, or that the treatment is experimental. You may not request an independent review if the requested treatment is not a covered benefit in your health plan. Who performs the independent review? The independent review process provides you with an opportunity to have your dispute reviewed by experts who have no connection to you, your medical provider, or your health plan. The independent review organization (IRO) assigns your dispute to a clinical peer reviewer who is an expert in the treatment of your medical condition. The clinical peer reviewer is generally a board-certified physician or other appropriate medical professional. In some cases, the IRO will also consult with an attorney or other insurance expert. When can I request an independent review? You can request an independent review whenever your insurer bases its decision to deny coverage on a medical judgment. In most cases you cannot request independent review until you have completed the internal grievance process, but you may bypass this process if both you and the insurer agree or the IRO agrees that a delay in receiving care could jeopardize your health. The independent review must be requested within four months of the date listed on your grievance resolution letter. How do I request an independent review? The grievance resolution letter should explain how to request an independent review. Send your request for an independent review to the address provided in the insurer s final written decision letter. Be sure to include: your name, address, and phone number an explanation of why you believe that the treatment should be covered any additional information or documentation that supports your position (photocopies) if someone else is filing on your behalf, a statement signed by you authorizing that person to be your representative any other information requested by your insurer 7

8 After your insurer receives the information, they must send all relevant medical records and other documentation used in making its decision to the IRO within five business days. The IRO then has five business days to review the information and to request any additional information it may need from the insurer or from you. Then what will the IRO do? First the IRO will review the request to verify it has no connection to the insurer or health care provider. Then the IRO will review the file to determine if it is complete. You or your insurer may be asked for additional information. When the IRO has all the information it needs, it has 30 business days to make a decision. The file is forwarded to a clinical peer reviewer who has relevant expertise. In reviewing a case involving medical necessity, the IRO and its reviewer are required to consider all of the documentation, including your medical records, your attending provider s recommendation, the terms of coverage of your health plan, the rationale for the insurer s prior decision, and any medical or scientific evidence. It must limit its decision on a case involving experimental treatment to whether the proposed treatment is experimental. After 30 days, the IRO will send its decision letter to you and your insurer. Federal external review process: Most health plans in Wisconsin are required to follow the federal external review process. Under the federal process, insurance companies may choose to participate in either an external review process administered by the U.S. Department of Health and Humans Services (HHS) or to follow the external review process regulations developed by the U.S. Department of Labor (DOL). HHS has contracted with Maximus Federal Services, Inc., to provide independent external reviews under the HHS-administered process. Information on this process is available at externalappeal.com/ or by calling Health plans that choose to follow the DOL external review process must privately contract with at least three nationally accredited independent review organizations. You send your review request to the health plan. It must have a process to randomly choose one of its contracted IROs when it receives a request for an external review. What if I need medical attention now? If you believe you need treatment urgently and that waiting the 30 days for the IRO to complete the standard independent review process could jeopardize your health or life, you may be eligible for an expedited process. Send your request to both your insurer and the IRO at the same time. The IRO s medical staff will then review your request and has the authority to determine if the grievance process may be bypassed. You will be given a decision in 72 hours or as soon as your health condition requires. 8

9 Do I have any other options? If you have already gone through the grievance process and still are unsatisfied with the results you can: File a complaint with OCI. Contact the Managed Care Specialist at OCI who will answer questions about your rights and responsibilities, including your right to file a grievance and to an independent review. The Specialist can also assist in urgent situations. Hire an attorney. Take your complaint to small claims court. Your employer may have insurance experts that might be able to help. It may also be beneficial to contact the Department of Labor, the Centers for Medicare and Medicaid Services, or the Department of Health Services for help with your complaint. Employer self-funded complaints: Other Resources The U.S. Department of Labor regulates employer self-funded health plans. You can file a complaint or submit a question by contacting them at https://www.dol.gov/ebsa/contactebsa/ consumerassistance.html or by calling their toll-free number

10 Step 1: Get to know your health plan Grievance and Complaints Worksheet Company name: Company address: Company phone number: My health plan is through: address city state zip code [ ] My employer [ ] A policy I bought myself [ ] An association-sponsored policy (such as through a trade, civic or educational organization) [ ] Other: What is covered under my health plan: [ ] Are the doctors, hospitals and other medical providers that I use in the plan s network? [ ] If I choose to use a doctor outside the provider s network will I be covered? [ ] Can I change my primary-care physician if I want to? 10

11 [ ] Do I need to get permission before seeing a medical specialist? [ ] What are the procedures for getting care and being reimbursed in an emergency, both at home and out of town? [ ] If I have a chronic medical condition, how will the plan treat it? [ ] Are my prescription medications covered by my health plan? [ ] If I want alternative medical therapies such as acupuncture or chiropractic treatment, will they be covered by my health plan? [ ] Are all pregnancy-related medical costs covered by the provider? 11

12 Step 2: Keep your records In an event that you may have a complaint in the future, it is important to keep all records relating to your insurance policy. [ ] Policy certificate [ ] Medical records/test results [ ] Letters from providers [ ] Records of all phone conversations, including Date and Time: Number called: Name of the plan representative: Summary of the discussion (including any promises made and the estimated time for any payment resolution): 12

13 Date and Time: Number called: Name of the plan representative: Summary of the discussion (including any promises made and the estimated time for any payment resolution): Date and Time: Number called: Name of the plan representative: Summary of the discussion (including any promises made and the estimated time for any payment resolution): 13

14 Step 3: Write your letter Make sure you use the following tips when writing your complaint letter: [ ] Did I include my name, address, phone number and my policy ID number? [ ] Did I fully explain the problem, including: [ ] dates of service? [ ] summaries of phone conversations? [ ] reasons I believe the plan s decision is wrong? [ ] Did I use policy language? [ ] Did I clearly state my intended resolution? [ ] Did I include photocopies of all supporting documents? [ ] If someone else is sending the grievance on my behalf, did I include a note signed by me? [ ] Did I send the letter to the address provided on the denial notice? 14

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